MDT Live: The Impact of 3D Printing on Healthcare
3D printing is emerging as a truly disruptive technology, affecting an array of industries including healthcare. It can be readily used for prototyping and parts manufacture, but stands to make a much bigger impact. As a medical technology, it provides solutions for custom prosthetics and implants, however, these are only the first steps for direct application of 3D printing in medicine. Research is proving that the technology could be used to fabricate living tissue and potentially even resolve the organ donor shortage by enabling the creation of fully functional replacements. On this episode of MDT Live, hosted by MDT Editor-in-Chief Sean Fenske (@SeanFenske), our expert panel discusses: How 3D printing is being utilized for medical applications today. The future for this technology and where it will make the biggest impact in healthcare. The challenges that lie ahead, such as the regulatory environment. The panel includes: Michael Drues, Ph.D., President, Vascular Sciences & MDT Editorial Advisory Board Member Todd Goldstein, Ph.D. Candidate, Lead Researcher - Orthopedics Laboratory, The Feinstein Institute for Medical Research, Hofstra - North Shore-LIJ School Of Medicine (@NorthShoreLIJ) Mick Ebeling (@mickteg), CEO, Not Impossible Labs (@NotImpossLabs) Special thanks to this MDTLive's sponsor, Stratasys, for making this event possible. Transcripts 3d printing is proving to be a disruptive technology for not only the design and prototyping space but in the real world applications as well this is evident in perhaps no greater area than that of health care where the technology is already being implemented to develop custom prosthetics creating tissue for implantation and enabling the printing of surgical tools while there remains a 3d printing promises the hope of contributing to a truly personalized healthcare solution for patients hi I'm MDT is editor-in-chief Sean Penske and with me today are Michael drew's president of vascular sciences Todd Goldstein PhD candidate and lead researcher at the orthopedic laboratory at the Feinstein Institute for Medical Research at Hofstra and nick Spaling CEO of not impossible labs gentlemen thank you for joining me today I'd like to get started by briefly discussing some of the unique applications where 3d printing is being used in healthcare today make let's start with you so a little bit about what we're doing and we back in 2013 November 2013 I packed up 3d printers use of plastics and laptops and I left for Sudan a specific reason and the very south of Sudan bordering South Sudan and Sudan called the Nuba Mountains and the goal of the mission was to go to one of the most remote places they are no electricity no running water and to create a 3d printed prosthetics for a young boy named Daniel lost both of his arms in the war so we went over there we were able to successfully make the trip in spite of a cease-fire ending mid trip and Daniel was able to feed himself again for the first time in two years but trust that the big accomplishment that we're most obviously Daniel be able to feed himself was an amazing story but we were able to r to be able to 3d prints so when they actually back and I landed in Los Angeles I looked up and down the sound and I received two emails from doctor to doctor time containing the they're managing doctor in this hospital of two prosthetic that were made while I was actually in the air so and this is actually have an example this is a prototype for example an arm that we made for Daniel so you can see very simple very crude but incredibly incredibly functional in terms of whether they go to great thank you Todd can you want to say a few words about some of the current applications so far in the realm of you the answer to show engineering so in my lab we are working on using three by outpointing to create you know bones and cartilage tragus so recently we've worked on producing a trickle segment which has no multiple cell types also uses PLA and along with you know the living cells so we have our own manufacturing process that we're working on creating so we can actually put it all down at once you know the PLA in the cells and actually keep them all eyes so the different realm but also similar way to help you know children breathing issues on their own function pretty remarkable project and make you want to speak to some of the other areas John thanks for the update be part of this discussion and I apologize I'm fighting a little bit of a cold so I'd like to just real quickly takes about 45 applications that most people are not doing right now you mention surgical instruments will match in this natural habitat scenario your nano our position calls for a scalpel but unlike in traditional surgery where a nurse picks up a scalpel and gives it to the surgeon the positions voices picked up by a voice recognition system her 3d printer and then a scalpel miraculously shows up for the surgeon to use the surgeon uses that scalpel to do what they need to do they then instead of throwing it in the trash day they strode into the recycle bucket with those materials are working are are used all over again think that Star Trek it's actually not intellectual property has been developed for that some of it developed by myself and where even are not linked enough places 82 second quick example is an implant we now have actually 3d printed devices that are have been implanted in a patient's body in a permanent way a permanent implant is defined by FDA has a greater than 29 day indication but we have devices in patients were actually much more much longer than that the third example is combination products a combination product is not just a medical device or drug or biologic but a combination of all three of those things devices that either have already or could be loaded with drugs or biologics to be implanted in patients in the fourth example is printing pills so we actually now are printing pills that contain medications that can then be literally picked up and swallowed by the patient just like a pill that you would buy and in the pharmacy in Austin certainly not least quintessential example of biomedical 3d printing is printing of living tissue now the question becomes what could we used this living tissue for well it's one thing to talk about using this tissue for replacement of organs but quite frankly any of that what else could be used as to where we can actually use it for testing drugs that bring a drug onto the market is an extraordinarily efficient process and so we can actually use this what I call engineered tissue to totally what turned the way we do drug clinical trials upside down it's one of many examples of how the device companies and drug companies can be working together to do as we would say here in Boston some really wicked cool and that's just the tip of the iceberg that's just the I mean those are some fantastic some fantastic innovations kind of brings us into the next question what's what's ahead for 3d printing in healthcare and where does it stand to make the biggest impact will go back to make for that one you know I think that you know the way that we look at 3d printing right now and obviously my colleagues on this this phone caller doing some amazing and wicked cool stuff we are we gonna look at this from the standpoint of lowest-common-denominator so we're looking at ways to predominately work with external external creation devices or technology or solutions that will replicate or replace what much more expenses so I think what we're most excited about is not necessarily the creation of the next greatest thing but the replication and disruption more extensive harder harder to acquire things so it's a pretty simple principle of how we operate but you know our principles technology for the sake of humanity and I think the 3d printer represents the you know the equivalents and said before the printing press in the box except for now we're not just printing you know little black marks on my piece of paper but we're actually twenty now the potential to print up solutions that can truly change people's lives so that's why we we approached everything in 3d printing is what's the functional for functional lowest-common-denominator need and how do we replace replicator disrupt that which is already need and Todd you want to take that as well so for me working in biologics and soul into biologics for US only imagine something where you can make a huge impact us so you're in the or and the doctor goes well you know we need to replace out three-quarters of the liver or have to cut it out or a kidney or so that we can just go OK at the start of the surgery go are at stake out themselves we can buy a print them into an organized a few hours later but actually ready to put this back into the patient on the table and it's kind of like on the spot the man for organs are trying to figure out ways to do this now with bone and cartilage you can do so it's a one stop shop basically you can replace your going on the table so now this would in this would cut the list for organ transplants down and you could do this you know anywhere in the world just like we're talking about where the route to work on it so you can also send these temperatures to anywhere in the world they can do surgery that they're trained and actually create organs on the spot in there are such a world that we're looking to push forward to that would make a huge difference in a lot of different surgeries are going on and we'll come to you for the next well I already shared with you and your audience shown some of my favorite applications for 3d printing in the future Drummond opportunity perspective I think one of the greatest opportunities in the future of 3d printing is really not a technological and/or regulatory won the regulatory past more specifically to bring devices or products I should say like this to markets for the FDA is truly the wild wild west into me that represents shoot opportunities not just to get these products on to the market but to do so in a way where you can actually use the regular regulation to create a barrier to entry competition this is like a competitive regulatory strategy so in other words how can I bring my 3d printing technology on the market not just to get it on the market again anybody in a monkey that I want to be able to get it onto the market and at the same time make it more difficult for the people following in my footsteps to get there is onto the market as well and because the regulation is very very poorly defined in this area right now that's a tremendous opportunity to do that and will definitely try and try and touch on more regulatory issues out later in the discussion for right now I'm going to go back to Mick and ask what are in addition to regulatory what are some of the other challenges for this technology and healthcare 3d printing that is for us to in terms of the challenges it's it's really an acceptance this as a viable alternative and solution and the reason we're doing that and approaching it the way they were approaching is we're not really looking for the medical world acceptance of this this is the solution to his acceptance or adoption is really dependent upon the people that these solutions will seek to serve in the first place so doesn't have to be pretty doesn't have to be polished but if it accomplishes this fundamental need and you're able to get it and circumnavigate the insurance companies or the medical bureaucracies or the FDA or any of these things because what we do is always free or incredibly cheap and we publish how to do it online we don't seek to be a distribution system we don't seem to be or retained IP around the devices that were treating we're seeking the destruction in the distribution of things that were doing so for us the limitations are less on regulatory bodies or or governmental organizations or the medical profession as a whole and more about just getting the knowledge and information to the masses you can actually utilize it and then because our theory is open source they can actually make it better for us we would consider it to be a failure that within months after releasing one of the things that we've created in the marketplace if we it hasn't been made better faster stronger by the crowd and our original product or invention or innovation almost be obsolete within within a couple months period I think that open source diane is is certainly something where the perhaps even its own discussion I think that that brings in a whole new element to the the 3d printing technology preciate Todd would you like to comment on the some of the challenges sure so in my room there are so many challenges and so many hurdles so we have to deal with not all only not only defect that there's the FDA and regulatory issues to deal with but also creating a lot of the customized tools we need to make this to make this a streamlined process from 3d printer in two patients is a extraordinary technical challenge as well having physicians willing to take this step 2 worked out you know taken two trials on there are treatments available for other stuff that might not be the best treatments and saying like hey we have this great technology we want to try and expanded out actually treat people with it but if there's an alternative alternate surgery helpful you more leaning towards that because it's true it tried for us so we started working on some of the different types of technologies that don't have any treatments and are looking forward to our acceptance now has to do with really with the FDA in regulating all the different governmental bodies moving forward so it is in itself an entire discussion and also a huge challenge thanks for that those insights will come to you other than the regulatory what are some of the challenges that you have encountered so that's a great question Sean and I was already has been discussed there are a lot of challenges one on the material side and the second on the machine site so first on the materials when it comes to biomedical applications of 3d printing especially when you're talking about putting devices inside a patient's questioningly the material selection that we have to choose from is pretty bad to be polite and extremely limited and clearly we need better materials that we can use to make these kinds of products auto but on the flip side it really quite frankly is kind of nuts to continue to use D 3d printing machines which largely come from the aerospace and automotive and other industries to be able to use materials that are specifically design for biomaterial applications for example if we talk about making materials out of proteins or lipids carbohydrates true biomedical polymers never mind putting the whole notion of being able to use the existing machines to print products like that please notice I'm not calling them medical devices I'm calling them products many ways these are combination products you know we need better machines we need better materials and we need more people working on those things you know what I want to jump back to something that make it mentioned and that was the the open-source aspect to go back to you for this one on on open-source you know open first combined with 3d printing as you kind of alluded brings in a whole whole bigger development aspect to make things better to keep them updated how does how does the open source movement tie into 3d printing and what benefits does it break you know I think if you look back to you essentially the medicine man was was created it was there was a personal need coming from an individual or a family to try to get outside help or support in and you know your post in their prayers or you know sticks or what have you those inventions or variations or or treatments were invented and I think that when you look at what open source is open source really is just a representation of unfettered sharing of information and for a large large part that's what the internet you know you you can't you could say the most crazy bizarre thing google it you can learn about it right away so there's this near internet access to information and i think what we're trying to do with the working on a possible is to take that into the physical realm and take it a visit around as it relates primarily right now to things that apply to someone's medical condition and again these are external conditions the way that medicine I think the way that medicine will exist in the future if you look at Smart patients you look at patients like me you look at data sharing information sharing you just have this is the son of the intelligence of the masses will always always be greater than the sum of the intelligence of even a room of distinguished professors or doctors or MD's the sound of that intelligence is a good experience and hands on you know day-to-day interaction with the disease is going to be able to provide doctors to patients to other people who are suffering from that particular syndrome choose to be able to help that situation get better and I think that's what open-source really represents is that unfettered sharing information so that people have access to better treatment now are taught is is open source as as big a factor in st. issue engineering in 3d printing of tissue is come into that realm or is that really not quite a fit the tools that we used to create these constructs and Eastern Europe grass will make them available open-source just because we want other people to actually be able to do similar stuff to create this environment to help each other like I was saying where they have all these powered masses however because you have to have quality control along this in the health professions it's kind of hard to do everything open source could you really need to have these things should be controlled and follow through all the different regulations so it's unaware of any sort of machine was open source that you can create something to you know cultures and stuff like that influence into a person who controlled by large numbers it's a big investment to get this sorted I wanna get a return on their money which I understand however in the research and development phase we try to make everything available open-source republished papers about how you tell methods are a lot of open source journals so we supported but it's just sayin tightrope we have to walk on according to figure out the best way forward and we're going go to you what's been your experience with open source specifically to you know 3d printing with health care well that's a good question and i would like to just amplify a little further would in terms of the regulatory challenges when it comes to software and general but open source software in particular one of the important differentiations in using 3d printing in the role as opposed to perhaps other industries as we have things like designed controls we have things like verification and validation in so bottom line that makes it a real challenge when you're using software that choice a is not up or or locked out and that is not going to make it any easier to get you through the regulatory or FDA process so the best advice I can give for companies wanting to use open source software in then actually commercializing bring it on to the market is to do the following if you don't want to start from the beginning an open source product but as soon as you get it to the point where it's doing what you wanted to do lock it down and now go through the traditional design control verification validation and don't make any more changes to it so that's the only the best in handling the open-source challenges from a regulatory perspective and then you cannot let us right into our our next question which is start with Mick what are what regulatory trainers need to a car for 3d printing to move forward just ask her questions to microseism Michael your your advice on this is 2217 is committed not to make changes is that they do understand that correctly that's a good question and to be honest that has nothing to do with software that's that's a dilemma that we face in medical device development all the time but bottom line in order to commercialize something you need to have a go through design controls assuming that it's a class to a class 3 product its class one product a lot of those devices are exempt from design controls but nonetheless you have to have a lockdown at least for the current generation and then of course you can make changes for there are ways for example doing a letter to file where you can make a change in a design again I don't care if you're talking about a physical which it philosophically it doesn't matter there are ways to make changes in a design without going through a formal regulatory review we can do that was something called a letter to file but that's a topic of discussion and if you're interested in we need to talk about it for you it is an option but it's also an option that gets a lot of medical device very very frequently so I think that's my question really originates from just a distinction in terms of the views represented on this chat live use that I express I'm expressing about how we go about this we're not really thinking about regulatory bodies were not really thinking about how to get something through a system just the mere concept of the words don't change something once submitted is just like send shivers down my spine as that's not how we think we're seeing you there some way to make it better make a better immediately and then disclosed that in a release for release early release it as quickly out there in the marketplace as possible but not necessarily that one is right and what is wrong I just fundamentally where we come from our position is that there's somebody needs with a device a man who is any regulatory body to say that way you can have that you need to wait so you know cover page UTVs report that's just not something that we even contemplate in terms of how we think our entire process is just let's get it out there as quickly as possible that's what the community in the crowd refine it tested find hairs and there will be areas and have been continued to push it forward to say that I am trapped between those two worlds sure that's why I was very clear to say that I don't think that one world is right or one world is wrong it's just the way that we operate is it's a bit of a Robin Hood you know it's a bit of a power to the people how do you get it to them as quickly as possible but you know we're not dealing with chemicals are not dealing with things that are there in the pharmaceutical world we're dealing with things that are marked as yet it's also I think the you know obviously serving Sudan with the technology the way you did I think you're obviously dealing with a much greater obstacles to success beyond FDA regulation I mean you know you're you're enhancing life but does that mean the way we're doing things should be changed or is there a time and place for you know for each each aspect I think that you know that I think the way that we do things in this country should absolutely be changed I don't think there's a better person in the medical profession the academic or practicing who would disagree with that it's just a question of how much it needs to change in how quickly we can prove it to demarcations a media marketing system and we need to once once you are governed by the the capitalistic tendencies insurance companies or medical facilities at things like that then you automatically have something in conflict with it therein lies the kind of thing that has to be navigated and we will always be navigated because wow what we're trying to do is trying to take things to the masses and try to get things then quickly as possible we also believe in capitalism to believe that a way to to progress is toxic to incentivize people to progress to transfer the invent things so I think that but we need to change just a strike that point yet again thank you and Todd will go to you and I know obviously you want like you mentioned you a tightrope that's obviously a much more difficult area to work in with regard to regulatory situation so what are your thoughts on regulatory changes that are needed with regard to 3d printing so I think the whole concept and i can only speak towards actual you know implanting this inside and not deal with prosthetics are dealing with the surgical tools etc just using 3d printing as a way for tissue creation so for us there more needs to be just a definition of what you need to do to process your tissue to be allowed into it what is what is deemed not see how is the process even affect their the cells because that kind of stuff isn't defined by the FDA has it been like for a while what's this the race trying to get this done first and no one's really sure what the actual outcome should be or can be so for me to make these constructs an implant them that's great however the government hasn't square or the FDA and other regulatory bodies have been said ok this is what's your dick success you go to the market there is no this is a failure and this is the reason why you need to adjust it so it's an interesting kind of time to sit through an interesting for someone to sit and watch all these things are going on that's really really interesting so it's kinda like no one of the three different coverages that there are leading the next revolution will this year is kind of like the next medical revolution of our creating drugs plus these treatments etc definitely exciting and interesting time for the for the for this technology Michael jump over to you and I know you very set up a bit about regulatory issues and challenges but you have anything additional the way perhaps regulatory or what regulatory changes would would be necessary for 3d printing to really grow within the healthcare industry well that's a great question Sean thanks for the opportunity to chime in I don't think we need a regulatory change I think we need to regulatory system specifically designed for personalized medicine 3d printing of medical devices is personalized medicine just like pharmacogenomics is to drugs or or biologics from a regulatory or a philosophical perspective it's exactly the same in our current regulatory environment is not designed either on the device ID or the truck side for personalized medicine and I'll give you just one quick example in the medical device we know we have a few medical devices have been printed and brought to market using the 510 cake in my opinion that's not the 510 K the PMA the HDE the diNovo all of the commonly used medical device pathways to market they are not the appropriate way to market we should be using for personalized medicine of medical devices in this case 3d printing I have actually said publicly for the last several years that the best regulatory pathway to market that we have at the moment this is by no means ideal best one that we have today is also the least commonly used in there is something called the custom device exemption or the CDE I have actually also said publicly that in the future the CDE has the potential to become as commonly used perhaps even more commonly used then the 510 K into many people when they hear me say that they think you must be smoking a Sox well the CDE is the closest thing that we have to personalized medicine it is by no means idea on a really think we need something better and we have had discussions about creating a new regulatory pathway which i think should be the same for the topic of a different discussion and I'll leave you with with one last comment to think about on this one shown in that is the regulatory framework is designed for blockbuster products in other words if you're bringing a product onto the market was a medical device or a pill I don't care and your intended patient population is high as thousands or tens of thousands or millions it makes sense to do a clinical trial of perhaps a couple of dozen are a couple of hundred patients but in personalized medicine whether we're talking about 3d printing or pharmacogenomics it doesn't matter where you are intended patient population is one person what does a clinical trial even look like for one person now there is a solution to that problem as an engineer when I look at a clinical trial and I spent some of my time designing trials for companies I spend my time evaluating clinical trial designs for the FDA so when I look at a clinical trial as an engineer I see nothing more than a validation in two ways that we can do a validation one way is to validate the product in the way we do clinical trials today is to validate the product but the other way we can do a clinical trial the other way we can do a validation is to validate the process and so I think the answer to that question of how do you regulate how do you do a clinical trial of personalized medicine again devices are drugs that doesn't matter to me is to focus on validating the process that's the secret sauce not the product in the very last thing that all say with regard to tie rods work in the area of printing tissues although from a technology perspective that's wicked cool from a regulatory perspective there is precedent to that already we've been doing it in decades or four decades for example when we take tissue from one person implanted into another person or when we take tissue from an animal a xenograft for example an implanted into a person we do then we've been doing this in medicine for decades in the former case FDA has nothing to do with that because that's the practice of medicine in the latter case the FDA has something to do with that but it's still not real clear as to what we've been doing it for a long time now we get to the apex of that of that period when we're talking about printing tissues the question that we need to start out with what if any should FDA's role beyond that to begin with because that really any different fundamentally than taking tissue from another person or from an animal certainly something to be thinking about these are these are questions that we as an industry need to think about and discuss but these are also questions more importantly as a as a society that we need to talk about and discuss some great insights they're going to share with your reader question that we got asked about materials and they asked if if you are aware of any other materials beyond PLA and abs that we're going be able to be used for 3d printing as of right now most things that we do and and explore our in the consumer grade so that CBS MPLA but I mean you just have to look back a couple of years to see the demise of the laser printer for the color printer and see that the economics around that are based in the in the filament are based in the ink in the printer so I think you're going start to me party scene people printing in sugar printing with organic substances you're seeing people in carbon fiber and it was you know people printing in concrete and cement so I think that the amazing thing that's going happen and it's this is I'm not any suits their handwriting this is them different materials that 3d printers are going to be able to spit out that's that's going be a great thing and there's I just met with a young boy up in Seattle who printed and abs that than 40 different coats on just kind of monster sprayed onto the plastic and it made it just feels so I think you can also start to see things that you can do to the after extruded laments that will seal it will carry it and we'll turn it into you know better stronger faster that's an interesting I hadn't considered with the coating technology that that may be able to be added to maybe a framework or finished part yeah yeah I know yours is more of a more of a niche area but are you seeing material innovations in in your space so I can probably spend three hours just talking about the materials that we use in a special my space but like so there's no such thing as a lot of different blends of material so you know PLA with limestone with iron bronze we have Pali Capital lactone PCL ppl and then also all these other various composites also in the biologics anything that you can form until like a jello type substrate you can call it you can print it you know using alginates using different types of college and also sugars I mean even medals you can you really wanted to you could probably mix and match anything that you wanted to and you can come up with a new types of composite I know we do that on a daily basis here we mix different types of closets get the correct time we wanted the bottom for it breaks down so this in this this is going to be a huge huge boom for the 3d printers get away from just two types to think those pretty pretty amazing what what would be expected to be coming down the line you want to speak to the material innovations aspect for 3d printing yeah Thanks gone as I said earlier I think there's a lot of challenges on the material side as well as on the machines side and those two things are intimately related to one another because in biology the materials that we really would like to use very finicky very delicate materials and quite frankly we need more delicate machines to deal with them to print them in a biological sense of the word but once again one of the biggest challenges that we face here is on the regulatory side and let me just back out of 3d printing for a sec just talked about from a general medical devices material perspective we have lots and lots of companies medical device companies bringing medical devices market more than anybody could possibly come but on the other hand how many companies do we have that are developing truly neutrally novel biomaterials the answer is very very very few and that's another one of these things that's really holding us back and actually we have created disincentives for companies to do this because think about this if a medical device company has a choice between bringing a new device onto the market may not have an existing material or what I sometimes referred to as a bio friendly material versus a new device out of a new material ninety-nine point nine times out of a hundred they're going to choose the existing material because it is easier but it is also really holding us back and never mind when you get into some of these funkier biomaterials that are bioabsorbable when a material breaks down in the body not just physically but chemically now you getting suspiciously close to the Bailiwick of cedar to the drug side of the FDA and this is something that historically the medical device industry is really wanted to stay away from but one of the things I spent a lot of my time doing is helping companies commercialize truly truly novel technology where there are technical and regulatory challenges but we don't believe those are challenges but unfortunately the vast majority of people working in this industry at least from my experience have become very risk-averse and they just simply want to take the path of least resistance and so as a result that said a couple of times it pains me to say it but I think there's a lot of truth to it even in the it's not the technology that's holding us back not the science it's not the regulation is holding us back its people's attitudes present company excluded of course but it's people's attitudes that's holding us back great thanks for that and I just want to take a minute to give each you just may be a final thought of a sum sum up statement on 3d printing in healthcare kind of whatever angle you want to do you want to take Nick will start with you sure you know that the risk of being repetitive you know I think that the the angle that we approach the sad in a way that we view the 3d printing is 3d printing is just another soldering iron it's just another just another hammer through or are now it's just a another tool in the return of the power or the the circumnavigation and the bureaucracy to the people who actually need it so we believe that if people need something that you will they will go see whatever and they can to get that special something to provide a quality of life where medical release for some kind of freedom of mobility expression to a level and what we've seen since you is to just try to make that works pretty printing is an incredible tool but the the tool that I did I really we're not impossible really try to to tap into tomorrow is this just to have ingenuity and if you could get if you could accomplish the same thing by hacking open and breaking up and something that already exists an electric toothbrush or something like that and it can accomplish something just fire rewiring and re-creating a fundamental way to accomplish and you don't have to 3d press event a stick for us 3d printer there obviously provide so much access to creating exactly specifically with what you want and what you want to do so that's why we're so excited about to and use it and so many other areas but for us it's more of this fundamental concept of technology for the sake of humanity and necessity really leading to the creation of incredible inventions have a final word final thought this really say that people who don't have exposure to print them there should be scared to just go jump into it go to one of the different various stores or download one of the first officers tried print something out because you know they can have to explore try and get involved in doing something that you know potentially could really have a good impact and humanity you know whether it's a decade toys and ideas that you can rapidly prototype this you know 3d printing ecosystem just get out and try it because I didn't come from anywhere and from all the people of all different walks of life so you really should just do your research that involves great thank you and make your final thought final comment well thanks Sean and I and again I would just amplify well I think what he was describing his nike's phil has do it I agree with bottom-line 3d printing technology especially in medicine is wicked cool it has the potential to change this this not just as industry but this world in a number of ways not just an evolutionary ways but more importantly revolutionary ways and you know with all due respect to my many friends that are working in this area right now the stuff that we're doing today the beginning step in the direction it's the iceberg in the best is yet to come in finally because I do spend a lot of my time helping medical companies bring new revolutionary technologies onto the market through the FDA and Health Canada and organizations like that I think we really need to work with these regulatory agencies 2222 this better because quite frankly if everybody waited for someone else to be the first ones we also still living in caves and this is really holding us back yes there are challenges there are technical challenges there are biological challenges there are clinical challenges there are engineering challenges there are medical challenges regulatory challenges there are reimbursement challenges there are manufacturing challenges their intellectual property charges there are a lot of challenges but all of those challenges are solvable problems and the first thing that has to happen as todd has said a moment ago as we need people stepping up to the plate and say this sounds like it's a difficult problem but I'm willing to give it a shot and unfortunately in this risk-averse industry that there aren't too many people that are doing that anymore on the regulatory side I refuse to be labeled as the police in so many organizations derogatory folks I hate to say this there are viewed as the police because they're constantly telling people what they cannot do I do not take that approach as I was in a company just this morning I said to them you tell me what you want to do and I will figure out at least one probably more than one way to get it through the St that's the kind of attitude that we need not to focus on what we cannot do but rather to focus on what we can and then I think that I think that commentary stretches well beyond 3d printing so on to wrap up I just want to thank everyone who is tuned in today to watch a discussion on 3d printing certainly will be a topic that we keep up to date on as we continue to inform you of new innovations in the space for Mike Todd and make sure he editor-in-chief of MDT and this is Ben MDT lives look at the impact of 3d printing on health care thank you